Nokea
The nurse is feeding a client who experienced a right-sided stroke and has dysphagia and hemianopsia. Which of the following actions would be appropriate for the nurse to take? Select all that apply.
- A. Encourage the client to turn the head to the left occasionally while eating
- B. Add milk to the client's mashed potatoes to make the consistency thinner.
- C. Provide a straw for the client to use while drinking a fruit smoothie.
- D. Place food on the stronger side of the client's mouth
- E. Assist the client to sit in an upright position.
Correct Answer: D,E
Rationale: Placing food on the stronger side and upright positioning reduce aspiration risk. Head turning may not help right-sided stroke, thinning food increases aspiration, and straws are unsafe.
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The nurse is caring for a client with acute pancreatitis. After pain management, which intervention should be included in the plan of care?
- A. Encourage the client to cough and deep breathe every 2 hours
- B. Place the client in contact isolation
- C. Provide a diet high in protein
- D. Institute seizure precautions
Correct Answer: A
Rationale: Encourage the client to cough and deep breathe every 2 hours. Coughing and deep breathing prevent respiratory infections due to shallow respirations.
The school nurse monitors an 8-year-old with a history of asthma. The nurse notes mild wheezing and coughing. Which action should the nurse perform first?
- A. Call the health care provider
- B. Determine the client's peak expiratory flow
- C. Notify the client's parents
- D. Remind the client about avoiding triggers
Correct Answer: B
Rationale: Measuring peak expiratory flow assesses asthma severity first. Calling the provider , notifying parents , or discussing triggers follows based on the assessment.
The nurse is caring for a postoperative client who has D5W/0.45% normal saline with 10 mEq potassium chloride infusing through a peripheral IV catheter. What are appropriate reasons for the nurse to change the site? Select all that apply.
- A. Area around the insertion site feels cool to the touch
- B. Client reports mild arm discomfort after the infusion is started
- C. Edema is observed on the dependent side of the involved arm
- D. Intraoperative peripheral IV catheter was placed in the left antecubital region
- E. Serous fluid is leaking from the site despite secure connections
Correct Answer: A,C,E
Rationale: Coolness suggests infiltration or poor circulation. Edema indicates infiltration or phlebitis. Leaking serous fluid suggests dislodgement. Mild discomfort may be normal initially, and antecubital placement is acceptable unless complications arise.
The nurse is giving unlicensed assistive personnel directions for bathing a client who has a surgical incision infected with methicillin-resistant Staphylococcus aureus. Which instructions would be most effective for reducing infection?
- A. Assist the client to the shower and provide directions to use antibacterial soap
- B. Delay the bath until the client has received antibiotic therapy for 24 hours
- C. Use a bath basin with warm water and a new washcloth for each body area
- D. Use packaged pre-moistened cloths containing chlorhexidine to bathe the client
Correct Answer: D
Rationale: Chlorhexidine cloths effectively reduce MRSA. Antibacterial soap is less specific, delaying the bath is unnecessary, and a bath basin risks contamination.
The nurse is caring for a client with community acquired pneumonia. When collecting client data, the nurse should anticipate which findings? Select all that apply.
- A. Crackles
- B. High-pitched wheezing
- C. Hyperresonance
- D. Pleural chest pain
- E. Productive cough
Correct Answer: A,D,E
Rationale: Crackles , pleural pain , and productive cough are typical in pneumonia. Wheezing suggests asthma, and hyperresonance indicates air trapping.